Provider Demographics
NPI:1407912751
Name:ACTIVERXEYEWEAR
Entity Type:Organization
Organization Name:ACTIVERXEYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:COLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:518-785-4674
Mailing Address - Street 1:9 FIET AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-6715
Mailing Address - Country:US
Mailing Address - Phone:518-785-4674
Mailing Address - Fax:518-785-4675
Practice Address - Street 1:830 HOOSICK RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-6665
Practice Address - Country:US
Practice Address - Phone:518-274-5559
Practice Address - Fax:518-677-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7230-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7230NYOtherEYEMED VISION CARE